Content item |
Rationale |
Verification of “nil per os” status |
A historical feature that must be
verified on the day of surgery |
“Absence of peripheral nerve stretch verified” |
A prompt to document the careful positioning and padding of extremities |
Prompt for “Ultrasound Guidance” when used for central venous access |
The use of this tool decreases risk and should be documented. |
Accurate description of ventilatory modes over time, including documentation of tidal volume when pressure controlled ventilation is used |
Ventilatory modes may be changed during the course of the anesthetic, a reality for which the anesthetic record must allow. In the case of a handwritten record, documentation may promote clinician awareness of this important physiological variable. |
Airway pressure |
Important physiologic variable |
Fluid management summary box |
Important clinical information which may be difficult to interpret from grid portion of record |
Intra-operative laboratory results box
|
Promotes review of laboratory results and presents results and trends visually to the anesthesiologist. |
Regional technique details box: includes prompts for needle type and sizes, precautions, drug types and doses; include absence or occurrence of bloody tap |
Promotes completeness and serves as an easy reference for other health care professionals caring for the patient postoperatively (e.g. acute pain service, thrombosis team). |
Table 1: Selected Content Items for Intra-operative Phase. |